Dr. Ann McKee

Dr. Ann McKee is the director of neuropathology at the Department of Veterans Affairs in Bedford, Mass. In her research, McKee has discovered the disease in dozens of former football players. This is the edited transcript of an interview conducted with FRONTLINE's Michael Kirk on May 20, 2013.

Dr. Ann McKee is the director of neuropathology at the Department of Veterans Affairs in Bedford, Mass. In her research, McKee has discovered the disease in dozens of former football players. This is the edited transcript of an interview conducted with FRONTLINE's Michael Kirk on May 20, 2013.

So how does a brain come here? What happens when somebody's brain -- is it like FedEx?

Yeah, sometimes it's FedEx. It's usually couriered, though. We try to get the brains fresh, so they come on wet ice, you know, sealed in a series of plastic bags, but then wrapped in a Styrofoam cooler, basically, with ice, and then another cardboard box. They look like a pretty innocuous box that goes by airplane from wherever they've harvested the brain to here.

And when it comes here, then what happens?

Well, you know, we take it out of the box. We weigh it. We photograph it, all the external surfaces. Then we'll do a series of dissections where we dissect and section the brain. We'll freeze half of the brain, snap-freeze it at minus 80, and we'll store that in freezers for scientists that want to look at molecular or biochemical studies. Genetic studies will require frozen tissue.

Then the other half of the brain we preserve in a formalin-type solution. We dissect that, take lots of photographs, do a whole series of microscopic slides, look at it with all sorts of different stains for different things, and then come to a conclusion about what the diagnosis is. ...

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It's a special thing, a brain coming in, isn't it?

Yeah. Oh, it's a very special thing. I think because I was a clinician, I never forget that the brain is a human being. And the brain, to me, is a life. So it's a very special thing. I feel very privileged that someone has trusted me with this duty. ...

... How do you hear about CTE [chronic traumatic encephalopathy]? What do you think when you learn about it?

Well, actually, the first time I experienced CTE was a case from here. It was actually the case of Paul Pender, who was a very well-known boxer in this area. And he came to autopsy. He actually had been here at this hospital for a number of years, in the end stages of dementia, and because he was part of our Alzheimer's study, I was the person to evaluate his brain.

When I evaluated it, it was different than any brain I had ever seen. I mean, I've been doing this for 20-odd years, almost 30 years, and this brain was so different. He had such an extraordinary disease. You know, for a person who looks at patterns and different pathologies, this was something I had never seen before. And it was fascinating. It just had some characteristics that, in my experience, I had never seen. So I was particularly interested in that brain. ...

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When you see something that's different, that you've never seen before, sort of an anomaly, what's that like?

Well, it was just absolutely fascinating. I mean, it's like you're just knee-deep in trying to figure it out. I mean, this is just an extraordinary disease. And then you wade through the previous literature, and you try to put it in its place. Has this been described before? How does this fit in with what we know? And it really seemed -- it seemed much more expansive than anything that had ever been described before. ...

But we really needed more, more of these examples, to really make something of it. You can report a single case, but it won't be a very important study. But if you can find a series of them, and really understand what this disease is, you can make an important contribution. So I was really looking for another case of it, another boxer.

And that's when I happened to see that Dr. [Bennet] Omalu had reported very interesting findings in a football player, and I was fascinated by it. I went to see his poster. He had a poster at the International Alzheimer's [Conference]. He wasn't there. At least he wasn't at the poster when I was there. But I remember seeing it and thinking, that's exactly what I saw in this boxer.

My next experience is [former wrestler and co-founder and CEO of the Sports Legacy Institute] Chris Nowinski asking me if I'd be willing to look at a football player's brain. And I'm thinking, yeah. For a neuropathologist, this is like: "Are you kidding? I would love to."

Why?

Well, if you're turned on by what you do, which I am -- I mean, I love what I do; it's a passion -- you want to see it; you want to evaluate it. You want to just immerse yourself in this sort of -- it's hard to explain. But, you know, you're fascinated by the new -- the horizon of what you might see. ...

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... So a brain comes in from the courier.

Right.

Take me there.

Well, yes. We got the brain of Tom McHale. I knew he was a Cornell graduate. I knew he had played for Cornell, and I knew he was a nine-year veteran of the NFL. Then, when we looked at the sections -- again, this is a 45-year-old with terrific disease. I mean, he had florid disease. He has tau in all these regions of his brain. To know that he was 45 when he died, that is so extraordinary. You don't get changes like this until you're usually much older, and then only if you have a genetic susceptibility or something. So to see a change in such a young individual really was quite extraordinary.

How bad was it?

... It was about as bad as you get. I mean, it could get worse. It could be end stage. It could be so bad that it's starting to sort of completely involute [curl inward], and the brain is starting to just shrink to nothing. But it was pretty florid disease. There were what we call neurofibrillary tangles everywhere. They were throughout his hippocampus. They were throughout his frontal lobe. I had never seen anything like it in a person so young.

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And given that, and given the function of the hippocampus and other places, frontal lobes, what would one expect to see as symptoms of somebody who had disease spread like that?

Well, I would have expected hippocampal involvement, memory problems, lots of problem with learning, probably problems with executive function -- you know, planning, organization, judgment. That's about as far as I would have gotten.

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Do you tend to know the outside story, or are you focused at the very beginning on just what's before you?

I am supposed to know nothing about the case. That's the way we've set it up. So I know very little. Now, in these cases, I knew that they came in and they were NFL players, for example, but I had no idea how well he was doing or even, you know, the circumstances of his death. So I don't know how he's functioning. I just know that, in this brain of this very what I would call young man, he has substantial changes.

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And what is it, now you're three for three?

Yeah.

And what does that say? ...

You have to remember, this is what I do. I look at brains under a microscope. I'm fascinated by it. I can spend hours doing it. In fact, if I want to relax, that's one way I can relax. And I've looked at brains for many years, looking at tau, the patterns of tau that develop with aging, spent years doing it. And then I find these brains of these young people with florid tau in a pattern quite unlike anything I've ever seen. So that is extraordinary. You stop and you go: "There's really something here. This isn't circumstance. This isn't something that just happens. This is really something. We need to get to the bottom of it."

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You're a fan.

Yeah. I am a fan. ...

Fair to say you love football?

Definitely love. I was born with football. My brothers, my dad -- I would have played. I played football when I was a kid. It was part of life. It's a part of growing up. You know, it's a way of life. So I get it.

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Are you at that time, Ann, thinking about the implications to football of what you're discovering?

Oh, certainly. I'm certainly doing that. I can say, as a fan, when I would -- you know, as a neuroscientist, when I would look at the guys with those helmets, they looked indestructible. They looked invincible. I didn't realize those hits were causing any problems. Never in my wildest dreams did I think it was causing problems. I had heard about problems with knees and things like that, but I didn't think they were getting head injuries.

But when I saw this -- and I think it did make a difference, my background. You know, it's like you've been looking at an assembly line of cases for so long, you know when something is really out of order. ...

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The first thing I hear about you is a press conference you and Chris gave at the 2009 Super Bowl ... Tell me, why did you go there?

Well, I think we had this very small number of cases. I don't remember exactly how many cases, but we were trying to draw attention to this condition and [the idea] that this condition could occur, we felt, as a result of playing football; that just these concussions, and even the subconcussions of football, were causing this disease to develop in some individuals. That was extremely newsworthy, we felt, and people needed to pay attention.

And at the time, we also had the brain of -- I can say it now -- Eric Pelly, although I wasn't able to say it at that news conference, an 18-year-old. We had been able to get the brain of an 18-year-old who had died 10 days after suffering his fourth concussion playing high school sports. We treated it the same way as the others. I was shocked to find that, in the brain of this 18-year-old, there were little tiny spots, little tiny areas in the frontal lobe, that looked just like this disease. But they were just tiny spots, as though this is how this disease starts.

And the fact that he was 18 was just -- I mean, I had an 18-year-old at that time. You know that that brain is supposed to be pristine. It's supposed to be perfect. It's still laying down tracks. It's still developing. And this brain already had signs of very serious deterioration in it. I have no idea if he would have lived longer if it would have gone onto this other thing. But the fact that it was there, and he was only playing high school-level sports, I think that's a cause for concern. ...

And then the phone rings, and it's Ira Casson, [then-chair of the NFL's committee on mild traumatic brain injury].

Yeah.

Tell me.

Well, I was a little intimidated, quite honestly. You know, why is this guy that works for the NFL calling me? He wanted me to come to the NFL office and present the data. So I thought, OK, I guess I will. ...

What did he say they wanted to hear from you about? Or why were they calling you?

He wanted to hear the cases that I had found this disease in, and he wanted me to present those cases to this committee so that they could, I imagine, determine for themselves what the scientific validity of the findings was. ...

So when you go, what are you expecting? What is it like? Where was it?

Well, I'm a little intimidated. It's a big, fancy building. You know, it's New York. And I walk in, and it's a big, long table with a lot of men, almost all entirely men. I don't feel like it's a friendly crowd. But I'm going to, you know, show them what I have. ...

OK. So you're at the table. There they all are. It doesn't feel -- it's male.

It's very predominantly male.

Right. And it doesn't feel welcoming? Is that the word for it?

Well, they were very polite, but I know what I'm up against.

What?

I'm up against a lot of doubters. I'm up against people who don't think that any of this holds any water. So fine. I'm just going to show them what I have. And they kept interrupting. They kept interrupting and saying: "Well, there, see? You don't have -- " They had a lot of preconceptions about what they thought trauma did to the brain. In fact, one of the comments was: "You have no evidence of any trauma. You've shown us this tau, but there's no trauma." And actually, then I did show them that, on the brain of Wally Hilgenberg, there were traumatic lesions. There were what we call contusions. They're indisputable, indisputable evidence of trauma.

And then one of their biggest problems was, "That pathology that you showed is not anywhere where we would expect to see the effects of trauma, so it can't be related to football." And it was like, you know, just because you have these preconceptions about what trauma does to the brain, this is what the brains show. So I think you might be wrong about where trauma affects the brain. But it was things like that. ...

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Were they experts?

Well, they considered themselves experts. I don't know if they were experts. But, you know, they thought they were.

Are you an expert?

I'm an expert on what I see in the brain, and that's really all I presented, what I saw in these individuals' brains. And I also did say that, in my opinion, it was related to trauma, because I had only seen this pattern of changes in brains that had experienced considerable trauma, but a repetitive mild trauma, not the big blow to the head, not the big bleeding in the brain. This is, you know, small, repetitive traumas.

Head slaps.

Head slaps.

Helmet to helmet in "the Pit," on the line.

Right. Things that we used to think didn't affect the brain, didn't permanently damage the brain, but I had evidence that it did.

I don't know why they were hard on me. I mean, I think they did not want to believe it. At some point, it isn't so much about the data you present; it's about whether you believe the data. I did feel like it was against their beliefs, and I was going to have to change their beliefs, and they didn't want to. They were convinced it was wrong. And I felt that they were in a very serious state of denial.

Did sexism play any role in anything other than maybe how you were treated? ...

Female, right. Definitely. I don't want to get into the sexism too much, but sexism plays a big role when you're a doctor of my age, who's come up in the ranks with a lot of male doctors. Sexism is part of my life. And getting in that room with a bunch of males who already thought they knew all the answers, more sexism. It was like: "Oh, the girl talked. Now we can get back into some serious business." ...

So how did you feel at the end of it? So you walk out of there. Walk out with us. Tell us what that felt like. How did they say, "Goodbye. That's it. We're done with you"?

They were very polite, you know. They offered us lunch. You know, "Thank you for coming." Very polite. "We don't believe anything you said," but very polite. (Laughs.) You just sort of decompress afterward.

Did you think you'd turned anybody in the room, made anybody more aware, broken the ice a little bit with some of them?

No.

No change.

No change. I felt I understood them better. I felt I understood that they weren't on the same page as I was.

You understood them better in the sense that you knew what you were up against?

Yeah, I had a better idea how firmly they believed what they believed. ...

So did it change in any way, or help you come to any conclusions about how hard the road was going to be for you and Chris and anybody else who was involved in this issue?

I think it just made us more determined. If you really look at it, I felt what my job or my duty was was to let people know what I was finding as accurately and as factually as possible, and if they didn't want to hear about it, I was just going to keep presenting it until people get it. I knew that it wasn't going to be something people wanted to hear. It's not good news, but it's something they have to hear. I think it just made us dig our heels and think, OK, it's just going to be a really long uphill battle. ...

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OK. So [Alan] Schwarz and The [New York] Times, right after the MTBI [Mild Traumatic Brain Injury Committee], I think, is writing a lot of articles about all this. ... When it starts to appear there, did you have a reaction? Did you have a sense of, "OK, well, things are going to change now"?

I just don't know if I was that introspective. I think, at this point now, with all that's going on in the media, I have got a load of brains to look at, and I've got a lot of work ahead of me, so I'm pretty focused on my work. And I'm focused on that this is becoming, the brains were trickling in and trickling in, but now they're coming in fast and furious, and I'm trying to keep up, and I'm trying to get on top of that. So that's what was mostly consuming me.

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Why are the brains coming fast and furious now?

As soon as people became more aware of it in the general public, we had a lot easier time getting brains. Now, I don't ask for the brain, but if an individual had heard of the work or understood the work, then they were much more likely to donate the brain of their loved one. ...

Were you surprised [by] how many brains were available out there, that suddenly families are interested and want to know? I mean, it's one thing if it's one or two or three now and then.

It was very surprising, because I have been in the brain-donation business for a long time, and they usually take a long -- you know, these efforts take decades to really get up and running. But we had just no difficulty with -- I mean, it was difficult in that it takes a lot of logistics; it takes a lot of people; it took a big network. But in terms of people saying yes, it was surprisingly easy.

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Some of it must have been -- at least from what I've read, and we've talked to the Webster family -- they know there's something wrong with Dad.

Right.

They know he's not the same guy he was when he was playing in the early years, when he was a big breadwinner, and the money's screwed up, the relationships; there's rage where there didn't used to be rage, whatever it is, right?

Absolutely. And actually, even people, people that aren't even in those desperate straits, they were starting to talk about it. There were NFL players out there that were talking to their wives and saying: "You know, this work, really, I think this might be something. I'm experiencing some problems, and I'm thinking I should donate my brain to this work."

That's pretty amazing, actually, when you think about it.

It's incredible. And then the other thing that you have to remember is that some of these people were committing suicide. Suicide is so awful. It's so hard on families. I mean, being in this business, you see -- you just see a lot of heartache. And suicides rip a family apart like nothing else. We were getting brains of suicides, and that really turned the work. It started becoming something you just couldn't stop, because these families were so affected by these individuals taking their own lives.

Why were they killing themselves?

Well, suicide is very complicated, and we can't ever know exactly what the reason was. But we have found the early stages of CTE in a number of these individuals who have committed suicide, so there is a definite concern that the changes that occur in the brain in these individuals, in CTE, predispose or increase the risk for suicide. ...

And they're not, as I read about it, shooting themselves in the mouth or the head. Or they're doing things to keep their brain intact. They're drinking antifreeze. They're, you know, killing themselves other ways.

Yeah. Right. Well, and there were three NFL players who shot themselves in the chest. One is Dave Duerson, who actually let his family know he wanted to donate his brain. But then there have been other cases, other NFL players, including Junior Seau. And you know, those cases speak to me. I think that means something, that they took their lives that way.

What does it mean?

I think they wanted people to examine their brains. I think they wanted, on some level, for them to be part of the research. ...

OK. So what are you seeing, as you get closer and closer and more and more brains that's different than what Omalu saw with Webster, [Terry] Long, and --

Well, I think the main thing is that you don't have to be at a professional level to be getting the kind of trauma that leads to this. Owen Thomas was an amazing case. Personally, it was probably one of the most -- you know, I don't know. What do you call that, the case that changes your concepts, the case that -- a pivotal case.

Here is a 21-year-old, played college football. How many people play college football? And, you know, he dies of suicide. We don't know if that's related. But in his brain, he has unmistakable changes of this disorder. And not just in one or two spots like Eric Pelly, but in like, 20 spots, in a lot of spots in his frontal lobe. He's 21. He's so young. You know, that changes the game to me.

And then, that he -- you know, that he took his own life, I don't know. Again, maybe I read something into that, but it says something to me about his awareness of his condition, and that it breaks your heart, you know, that we could have athletes who are doing something that they love, because they love it, and it could be really damaging themselves in a way that's so destructive. ...

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OK. So the hearings.

I hear about the hearings. I think I was called, or I had an email that they wanted me to go to these congressional hearings. This is all a big surprise to me. I've never had this kind of call before ... And I don't know exactly what to say, because I've never done it before, but I decide that I'm just going to tell their stories. I'm going to tell the stories that these people trusted with me to tell. That's what I've got. I've got five or six cases. I'm going to tell the stories, and I'm going to say what I think they mean. And to me, they mean, if they hadn't played football, if they hadn't done these things, they wouldn't have gotten this disease. And that's something that the whole nation needs to pay attention to, because we don't want our kids going out and playing sports at a risk. You know, we need to understand the risk and be able to make intelligent choices. ...

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One of the things that happens as a result of the hearings ... suddenly you guys get a million dollars from the National Football League.

Yeah.

How does that happen?

It happened overnight. It was a complete surprise. I got a call from a reporter. I wasn't actually at my house. I was running an errand. I got home, and my kids told me that a CBS reporter wanted to know what I thought of the gift of a million dollars. That was the first I heard of it.

And what did you think of it?

I was like, floored. I had to call all the colleagues and try to figure out what was going on. But I think it became official news on the television, right? So that's how I found out about it.

At the time, what did you think was going on?

I think they recognized they had a problem. They certainly had a problem with public perception, and they needed to address it, at least publicly, or at least in some way. So they offered that up as a way to say that they're working on the solution. And in fact, they were. Actually, the million dollars was very helpful. I think they needed that for public relations at that point.

It was public relations.

And it was helpful. They needed it, and we needed it. I mean, it was helpful. There's no question it was helpful. And I also should say, they did not put any thumbs on us. We did not have any strings attached. There were no strings attached. We were not obliged to tell them what we were spending the money on or what we did with it. It was really a remarkable opportunity for us. And so, for whatever reason that they gave us the money, it was of tremendous benefit to the work. ...

So it's the summer of 2010. How do you hear about Owen Thomas, and how do you get the brain? What are the facts of the case, and what do you find when you look?

Yeah. I don't remember exactly how we got the brain. I know in retrospect that the family wanted to donate the brain because they thought he would be a control, because he had loved football. They had heard about the work. They knew how important football was to Owen, and they thought he would be -- if they could contribute to the work in any way, they wanted to.

I remember looking at the brain, expecting -- I knew it was a 21-year-old that had committed suicide, and I was fully prepared to see nothing. I remember late at night looking at the brain and thinking, just going to knock this one off. And I just -- it just floored me. It just -- I just couldn't believe what I was seeing, that in the brain of a 21-year-old, you can see damage.

And it wasn't just one spot; it was 20 spots. It was eating away at multiple areas of his brain. And a 21-year-old. Honestly, even now, it just -- it's something I couldn't conceive of before, you know. To see a process that's destroying brain cells and looks like it's spreading in such a young kid, I don't know, it just -- it just floored me.

Had he had lots of concussions?

He had never had a concussion, as it turns out. He only played football.

Ergo?

Ergo those subconcussive hits, those hits that don't even rise to the level of what we call a concussion, or symptoms, just playing the game can be dangerous for some people.

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Does the NFL get that message?

I think so. I mean, we've said it so long now.

At that time?

Oh, at that time, no, I don't think so. At that time, no. Subconcussive hits were just beginning to come into people's sight. We were just hearing from some accelerometer data that individual linemen were getting like 900 to 1,500 hits over the level of 10g's, which is, you know, a mild hit, but it's still something, every season. So if you think about it, if you play 10 seasons, you've got 10,000, 15,000 hits. That data was just starting to come in.

Wait a minute. Say that again.

Well, there's data from accelerometers. [Dartmouth University's Richard] Greenwald and other people were putting detectors in the helmets to measure the velocity of the hits. And even though it's an imperfect system, and it doesn't register all the hits, they were measuring 900 to 1,500 hits in a season for one player. And sometimes some players were getting 2,200 hits, one season, college football and now high school football. It's not just professional football. ...

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You know, I had the impression, or I have the impression that the NFL, at some moment, were themselves unhappy that Ann McKee continues to push and push and push. ...

Right, yeah. I would agree. They think I have an agenda. I do have an agenda, but it's not the agenda they think. My agenda is to tell these stories. I feel an enormous privilege. I hear heart-wrenching stories of families that are dealing with this disorder, and I just feel an obligation to talk about that and to tell it. I think it's important.

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What do they think your agenda is?

The NFL?

Yeah.

I don't know. I really don't know. I think they try to give me an agenda, but I don't know what they think it is.

How hard is all of that?

It's hard sometimes. It's hard sometimes. But I think I'm in an unusual position. And I don't know what to say here. Somebody asked me if I do this with my heart, and I do. I do it with my heart. There's just been too many stories, too many people that have trusted me. There have been players that have called me and said that they want me to examine their brain after death. And we have. And it is extraordinary. It's such a privilege to do this work, and I feel a huge commitment to do it.

Jesus, what's that like? A guy calls you up and says --

Yeah, it's just enormous. It was right after the paper on motor neuron disease came out, where we got a lot of flak from other individuals, doctors particularly. And a guy called me up from Rhode Island, His name was Ron Perryman. First of all, he's this extremely handsome black man. I mean, he's really handsome. And he wants me to meet him and his family. So Chris and I go down, and we meet him, and he clearly has A.L.S. [or Lou Gehrig's disease]. He's having difficulty with his arms, [and they] are almost completely useless.

But he can speak. And he tells us, you know, about how he played football for Boston College. He had a number of concussions, very severe concussions. Broke his neck. Required neck surgery. But he was played hard because he wanted to go to the NFL. His brothers played in the NFL. And he says: "I think I have the disease you're talking about. I think that the trauma that I had playing college football gave me this motor neuron disease." So that was an amazing privilege, that we could go meet him and meet his wife and doctor.

And then, four months later, he calls me back. I get another call from Ron Perryman, and he says: "Doc, I'm having a big party. I've got all my friends here, all my football friends. I'm going on what's called a terminal wean." That means he doesn't want to have his life maintained artificially on a respirator. He's not breathing well at night, so they're going to take off his support, and he's not expected to live very long without the support.

And he says, so he's having a big party to celebrate his life, and he said, "I just want you to know, doc, I want you to have my brain and my spinal cord when I die, so that nobody else gets this disease." And he died the next day. I mean, it's incredible. He died the next day.

It's a nor'easter, believe it or not. Everything's closed, schools. There's no power anywhere. But Victor [Alvarez], the amazing individual I work with, manages to get down there and harvest the tissue. He brings it back, and we do the analysis. Ron Perryman has a textbook case of CTE. So he's got the same thing. He had exactly what he thought he had. He was right. ...

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So when you go to Zurich, and I read about Zurich, and it feels like you just got hammered --

I did get hammered in Zurich. I was surprised by Zurich, because I thought, you know, you get the impression that you're getting somewhere. You get the impression that people are listening; people off the street are listening. I mean, not everyone likes to hear it, and most people would prefer that it weren't true, but you're getting somewhere. You get a sense of it. You get a sense of validation in general.

And I wasn't expecting to get to Zurich and be almost ambushed by some people who didn't want to believe any of it. They were coming up with all sorts of things to not believe it. And I really did think it was a belief. Looking back, I really see it's a belief. It's not the data. It's not, "Is the data sound?" It's whether or not you believe it. You can't change that. That's something everyone has to do for themselves.

What do they believe in, the disbelievers of you? What do they believe in?

Well, they told me, in a very outspoken and frank way, that they had read my papers, and they thought they were very poor science. There you have it. It's just very poor work. There's really no defense of that. There's nothing specific to counteract. There's no argument to that. It's like, OK, poor work. What can I say?...

Professional football players are presumably contracting, if that's the word for it, the disease you have become expert in.

Well, they're all vulnerable. Some of them probably are getting it. I just hope that the word is getting out enough that people make wise choices. That's going to have to be parents and coaches and athletic trainers and all of that. And I do see a big switch. I know people have asked me why I don't say football should be outlawed; football should be, suspended at a certain age. I'm not going to do that. I'm not an expert in sports or football. I can only tell you what I see and expect you to make up your own decision. ...

If you had children who were 8 and 10 and 12, would they play football?

Eight, 10, 12? No, they would not.

Why?

Because the way football is being played currently, that I've seen, it's dangerous. It's dangerous, and it could impact their long-term mental health. You only get one brain. The thing you want your kids to do most of all is succeed in life and be everything they can be. And if there's anything that may infringe on that, that may limit that, I don't want my kids doing it.

High school OK?

You know, I just don't feel like I'm in a position to say anything is OK right now. I'm not going to -- I'm not even sure about high school football, even well-managed high school football. We see this in some high schoolers. Let's figure out what this is and how to prevent it, and then I'll say we should all be playing football.

College?

I have a lot of college football players in my Brain Bank with CTE.

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In the professional ranks you could get the argument that this is the way these guys make a living, and they're professionals. And there were, God knows, 16 papers written by the MTBI that said professional football players are different, bigger necks, better musculature, thicker skulls. What do you say?

Oh, I say they probably are different. They're elite athletes. They're amazing athletes. That's why I love football. I mean, it's incredible to me to see them go out for an unbelievable pass and actually make the catch. It's just an amazing game of athleticism and skill. They're different; there's no question. They're huge, they're fast, and they're all these wonderful things. ...

I don't think it's just a disease of professional players. That's what I'm saying. You know, we've seen it -- I don't know where the counts are now, but I've seen it in a number of college-level players. Now, what distinguishes that player from the player who doesn't get it, that's what we need to know. That's what we need to know tomorrow so we can prevent this in college and younger players. ...

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... When you talk to a lot of the folks that are connected to the NFL, or former players, they all go: "Hey, I've got a lot of friends that are retired from the NFL. They're doing fine. And what you guys have been doing," talking about you and others studying CTE, "is looking at a small, select group of people that have committed suicide and such." So again, this big question of, how do you answer them? What is your definition of the prevalence? And where are we at this point with the science?

Well, the incidents and prevalence, we won't know those until we have a way to detect it in living people. Then we can look at thousands of people who play these sports, and really come up with an incidence and a prevalence. An autopsy series is terribly biased. All of that is agreed.

But, you know, I think to be truthful, even a selection bias in an autopsy sample, even if the family of an individual who is affected is much more likely to donate their brain than a person who had no symptoms whatsoever, given that, we have still been just ridiculously successful in getting examples of this disease. We just have an enormous experience with this disease now. We have over 70 football players with this disease, from all levels, and we've done that in five years.

I just don't think we could do that with a rare disorder. I just don't think it's possible. Even if we were selecting for families that thought that the individual had the disease, we have an enormously high hit rate. That would be extraordinary with any other disease to be able to pull in that many cases, just that were suspected. So I think the incidence and prevalence have to be a lot higher than people realize.

And I also think that given the worst of circumstances, if you take a single year, and you look at all the NFL deaths in a single year, and that's your denominator, and on the numerator you put all the cases that we've had with CTE of NFL players, assuming that we got the only cases of CTE of NFL players ever, anywhere, it's about 10 percent. Ten percent of NFL players get CTE. Well, that's a huge percentage, if you ask me. And that's the lowest it can be. ...

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We talked a little bit about this, but the NFL, to the extent it does publicly focus on it, talks a lot about concussions, about preventing concussions. What do you think when you hear that?

I think concussions are part of the problem. I think if you talk to anybody who's had a couple concussions, people that have had trouble recovering from concussions, they're very serious business. So the fact that the NFL is concentrating on concussions is wonderful. The NFL concentrating on concussions means that athletes at the college level, the high school level and hopefully at the Pop Warner level are going to pay attention to concussions, too.

The NFL leads the way. It's definitely the ring bearer. If they're doing it, then everybody does it. So I think it's extremely important that people pay attention to concussion. Is a concussion going to lead to CTE? No, probably not in most cases. But if you have enough concussions over a certain amount of time, yes, then I think you can lead to CTE. CTE is important; concussions are important. It's all important. You know, it's all about maintaining brain health.

It's almost like the NFL, ... I mean, they have to come up with some kind of a solution to something. A lot of people are talking about this, so they focus on concussions because it's a thing you can focus on. You can see when somebody got their bell rung. You can administer a test; you can hold them out of the game. But what you're talking about --

But we didn't know about this right at the beginning. You know, at the beginning we thought it was concussions, too. Remember, in 2009, 2010, we thought it was concussions. It wasn't until we started looking at that accelerometer data, we started looking at some of the functional data, we started seeing changes without concussions, that's when we started focusing on just the play of the game. So in the beginning, for them to focus on concussions, it makes sense. It was the obvious target.

But once they knew what you knew, then what should they have done?

I don't know, because I think they're really between a rock and a hard place. Football is an extraordinarily popular sport, and the whole game is played around this issue. The whole makeup of the game involves these subconcussive hits. I don't know how they're going to solve that problem. I don't think they know how they're going to solve that problem. So it's a harder nut to crack. ...

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